1 Cardiology Revision Phase2 Karl Wild and Rowena SpeakThe Peer Teaching Society is not liable for false or misleading information…
2 Stable Angina Stable Angina - A retrosternal chest tightness or heaviness which is brought on by exertion and relieved by rest. Symptoms – constricting discomfort in the front of the chest, arms, neck and jaw, Provoked by physical exertion, especially after meals and in cold, windy weather or excessive emotion Relieved (within minutes) with rest or glyceryl trinitrite. Causes – Mostly Atheroma. Anaemia, Aortic Stenosis, Tachyarrhythmia, Hypertrophic Cardiomyopathy Arteritis. Also – dyspnoea, nausea, sweatiness & faintness.
3 Unstable Angina – Angina of recent onset (<24hr) or a deterioration in stable angina with symptoms occurring at rest. Refractory Angina – Refers to patients with severe coronary artery disease in whom revascularization is not possible and whose angina is not controlled by medical therapy.
4 Angina Examination Signs – Anaemia Thyrotoxicosis HyperlipidaemiaAortic Stenosis (Ejection Systolic murmur radiating to neck) Check blood pressure Angina itself doesn’t have signs, it’s risk factors do.
5 Angina Investigation 12 lead ECG-During an attack – Transient ST depression & T wave inversion. Cardiac Catheterization, CT Coronary Angiography Exclude anaemia, diabetes, hyperlipidaemia, thyrotoxicosis and arteritis If resting ECG is normal, consider and exercise ECG.
6 Angina Management Address risk factors Aspirin 75mg dailyB-blocker/ Ca2+ – Atenolol/Amlodipine Both if uncontrolled on one Nitrates – GTN, Isosorbide Mononitrate bd Ivabradine/Nicorandil Ivabradine inhibits the funny channels at the SA node slowing the heart rate. Nicorandil is a K+ channel activator hyperpolarizing the cells and allowing smooth muscle relaxation and coronary vasodilatation.
7 Revascularisation PCI – Single vessel CAD and normal LV functionCABG – Triple vessel disease and abnormal LV function
8 Acute Coronary SyndromesST Elevation Myocardial Infarction (STEMI) Non ST Elevation Myocardial Infarction (NSTEMI) Unstable Angina Causes – Plaque rupture Coronary Spasm Thrombosis Vasculitis Emboli Risk factors – (Non-modifiable) age, male, MI in first degree relative under 55yrs - (modifiable) smoking, hypertension, diabetes mellitus, hyperlipidaemia, cocaine use, poor oral hygiene and high homocysteine levels. A diagnosis of Acute MI is based on an increase and then a decrease in cardiac biomarkers and either - Symptoms of ischaemia, ECG changes of new ischaemia, loss of myocardium on imaging.
9 NSTEMI ECG changes - ST depression T Wave inversion Could be normal
10 STEMI ECG changes – Tall T waves ST elevation New LBBB Later –T wave inversion Pathological Q waves
11 ACS symptoms - Acute central chest pain Radiates neck and armLasting >20 minutes Nausea Dyspnoea Palpitations
12 ACS Signs - Distress, anxiety, pallor, sweatiness Tachy/bradycardiaHyper/hypotension 4th heart sound Signs of HF and murmur Later - Pericardial friction rub & peripheral oedema
13 ACS Investigations ECG Bloods Cardiac Enzymes –Cardiac Troponin (T & I) ^ 3 hours after onset and peak at 24-48hr Creatine Kinase (CK-MB) ^ 3 hours after onset, peak within 24hr Bloods – glucose, lipids, U&E, FBC If cardiac troponin (T&I) normal 6 hours after pain and ECG normal, no MI.
14 PRIMARY PCI / ThrombolysisACS Management NSTEMI Oxygen Morphine GTN Aspirin 300mg PO Clopidogrel 300mg PO Atenolol PO / Verapamil PO Enoxaparin More Nitrate if in pain. High risk – GPIIb/Iia antagonist (tirofiban) Low risk – Discharge if 12hr Trop -ve STEMI Oxygen Aspirin 300mg PO Morphine GTN PRIMARY PCI / Thrombolysis Atenolol High risk – persistent/recurrent ischaemia, st depression, diabetes and raised Trop. Low risk – no further pain, inverted t waves/normal ECG and negative trop. Streptokinase non anterior MI Tenecteplase anterior MI
15 Non-occlusive thrombus No ST elevation -ve troponinACS Pathology Cause ECG changes Cardiac enzymes (Stable angina) (Narrowing lumen) Unstable angina Ischaemia Non-occlusive thrombus No ST elevation -ve troponin NSTEMI Ischaemia/Infarction +ve troponin STEMI Transmural infarction Occlusive thrombus ST elevation A 56-year-old man smokes 20 cigarettes per day and has a condition which requires treatment with a sulphonylurea. He experiences aching in his left arm every time he walks up hills, especially in the cold weather. Stable Angina An 80-year-old woman, who is a non-smoker, is normotensive and is not diabetic, presents for the first time with chest pain which wakes her up at night. The pain is central and radiates to her neck. It lasts 45 minutes and the electrocardiograph (ECG) shows T wave inversion in leads II, III, AVF. NSTEMI The Peer Teaching Society is not liable for false or misleading information…
16 Hypertension (HTN) Essential (primary) HTN = idiopathicSecondary HTN = something is causing it The Peer Teaching Society is not liable for false or misleading information…
17 HTN: causes of secondaryRenal disease: intrinsic, renovascular Endocrine: Cushing’s, Conn’s, Phaeochromocytoma, Acromegaly, Hyperparathyroidism Coarctation of the aorta Pre-eclampsia and HTN in pregnancy Drugs and toxins: alcohol, cocaine, ciclosporin, decongestants, adrenergic medications, oral contraceptives, corticosteroids, liquorice The Peer Teaching Society is not liable for false or misleading information…
19 HTN: diagnosis GP surgery BP measurements of adults at least every 5 years White coat syndrome = patients have elevated BP in a clinical setting but not in other settings due to anxiety experienced during a clinic visit. ABPM = ambulatory blood pressure monitoring HBPM = home blood pressure monitoring Cardiovascular risk assessment HTN retinopathy screening ECG to look for LVH Bloods: electrolytes, creatinine, eGFR, fasting glucose, lipids Urinalysis: albuminuria, proteinuria or haematuria ± albumin:creatinine ratio. The Peer Teaching Society is not liable for false or misleading information…
20 HTN: stages Stage 1 - BP in surgery/clinic is ≥140/90 mm Hg and ABPM or HBPM is ≥135/85 mm Hg. Stage 2 - BP in surgery/clinic is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg. Severe - BP in surgery/clinic is ≥180/110 mm Hg or higher. The Peer Teaching Society is not liable for false or misleading information…
21 HTN: lifestyle interventionsLower salt intake Reduce alcohol consumption Stop smoking Do more exercise Be less stressed The Peer Teaching Society is not liable for false or misleading information…
22 HTN: initiation of treatmentOffer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of: target organ damage established cardiovascular disease renal disease diabetes 10-year cardiovascular risk equivalent to 20% Offer step 1 treatment to people of any age with stage 2 hypertension The Peer Teaching Society is not liable for false or misleading information…
23 HTN: treatment The Peer Teaching Society is not liable for false or misleading information…
24 Heart failure A complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation. The Peer Teaching Society is not liable for false or misleading information…
25 HF: aetiology Ischaemic heart disease Cardiomyopathy HTNDiseases of the heart valves Pericardial disease Arrhythmias Alcohol Cocaine Chemo Severe anaemia Thyroid disease Idiopathic The Peer Teaching Society is not liable for false or misleading information…
26 HF: symptoms Left Right Exertional dyspnoea OrthopnoeaParoxysmal nocturnal dyspnoea (PND) Fatigue Swollen ankles Fatigue Anorexia The Peer Teaching Society is not liable for false or misleading information…
27 HF: signs Left Right Cardiomegaly Third and fourth heart soundsTachycardia Crepitations in lung bases Raised JVP Hepatomegaly Pitting oedema Ascites The Peer Teaching Society is not liable for false or misleading information…
28 The Peer Teaching Society is not liable for false or misleading information…
29 HF Investigations Chest X ray Bloods B-type Natriuretic Peptide ECGTransthoracic echocardiogram BNP – originally identified from pig brain. BNP is released when myocytes stretch, particularly from ventricular myocardium and increases GFR and decreases sodium reabsorption. It also relaxes smooth muscle reducing preload.
30 Chronic HF Management Diuretics – FurosemideACE-I – Ramipril / ARB – Candesartan B-Blocker – Atenolol Spironolactone Digoxin Vasodilators – Hydralazine & Isosorbide Dinitrate Spironolactone – aldosterone antagonist
31 Acute HF Management Oxygen Diamorphine IV Furosemide IV GTN sprayIf systolic BP >100mmHg IV nitrate Isosorbide dinitrate
32 HF Question A 75 year-old woman is brought to the Emergency Department by ambulance following an emergency call at 4 am. She is pain-free but very breathless. She has previously been diagnosed with congestive cardiac failure and is receiving drug treatment from her General Practitioner. In addition to an increased respiratory rate, list 2 physical signs of left ventricular failure that you would seek on examination. Increased work of breathing (use of accessory muscles), bilateral basal crepitations, third heart sound/ gallop rhythm, dullness to percussion at both lung bases (possible effusion). List two physical signs of right ventricular failure you would seek on examination. Raised JVP, peripheral oedema, hepatomegaly, ascites A chest X-ray is requested. List 2 X-ray features that would confirm your clinical diagnosis of heart failure. Cardiomegaly, batwing oedema, Kerley B lines, upper lobe venous distension List 4 treatments that would be appropriate for you to use for immediate relief of the patients symptoms of heart failure. Loop diuretic, opiates, nitrates, oxygen The patient makes a good recovery and is discharge home with follow-up in the cardiology clinic. List four classes of drugs that would be appropriate to use to treat congestive cardiac failure in the community. Diuretic (thiazide, loop or potassium-sparing), nitrate, ACE inhibitor, cardiac glycoside,
33 GOOD LUCK!!!